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INDONESIA
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Published by Institut Teknologi Sains dan Kesehatan RS dr. Soepraoen
ISSN : 2829341X     EISSN : 28285867     DOI : 10.62951
Core Subject : Health, Science,
Computer Science & IT Public Health
Jurmiki menerbitkan makalah asli, artikel ilmiah dan laporan singkat yang terkait dengan keilmuan terkait kesehatan (hukum, sistem informasi, manajemen dan klinis)
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 80 Documents
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KETEPATAN PENGGUNAAN SIMBOL DAN SINGKATAN PADA FORMULIR IGD RUMAH SAKIT PKU MUHAMMADIYAH GAMPING Nisa Rahmawati; Harinto Nur Seha; Rina Yulida
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.41

Abstract

The provision medical records quality cannot be separated from consistent recording in the use of medical symbols and abbreviations.. Symbols and abbreviations have been regulated in SNARS Edition 1.1. The uniform use of medical symbols and abbreviations aims to make the writing of terms understandable and can be used as a communication tool between health workers. Hospitals must have regulations, regarding the symbols and abbreviations used. Based on the results of preliminary studies at PKU Muhammadiyah Gamping Hospital, monitoring and evaluation have never been carried out regarding the use of symbols and abbreviations. Research on the accuracy of the use of symbols and abbreviations has also never been done, so it is necessary to conduct a review of the problem. This study used descriptive observational method with quantitative approach and cross sectional design. A purposive sampling technique used to 100 samples on the emergency room form for inpatients in the first quarter of 2022. The results showed that there was no monitoring and evaluation related to the use of symbols and abbreviations at PKU Muhammadiyah Gamping Hospital. The percentage of correct use of symbols was 27% and the percentage of correct use of abbreviations was 37%. The results of the analysis show that the inaccurate use of medical symbols and abbreviations is caused by the lack of socialization to related health workers, and there is non-compliance with officers in using medical symbols and abbreviations that have been regulated in the applicable guidelines at PKU Muhammadiyah Gamping Hospital.
ANALISIS KELENGKAPAN PENULISAN DIAGNOSA TERHADAP KETEPATAN PEMBERIAN KODE CEDERA DAN KODE EXTERNAL CAUSE PADA KASUS KECELAKAAN DI RUMAH SAKIT UMUM UNIVERSITAS MUHAMMADIYAH MALANG Ashila Irka Faza; Chyntia Vicky Alvionita
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.42

Abstract

In the implementation of coding in the case of accidents at the General Hospital of the University of Muhammadiyah Malang there are still inaccuracies in coding of 79.2% and accuracy of 20.8%. The purpose of this study was to analyze how the completeness of the diagnosis relates to the accuracy of coding injuries and codesexternal cause in case of an accident. The research method used is an analytical survey approachCross Sectional. To determine the relationship between the completeness of writing a diagnosis on the accuracy of coding injuries and codesexternal cause In the case of an accident, a statistical test was carried out with the testWho Squareusing the IBM SPSS application version 25. Using the saturated sampling technique, a total sample of 77 accident cases was obtained in the 2022-2023 period. In this study, the results of the diagnosis accuracy were 20.8% and 79.2% inaccuracy. This inaccuracy is caused because the officer did not do the coding for the codeexternal cause. Based on the SPSS results, it was found that there was a relationship between the completeness of writing a diagnosis and the accuracy of coded injury and external cause codes in accident cases at the General Hospital of the University of Muhammadiyah Malang. These results are due to the writing of the diagnosis which still does not include the chronology of the accident. This can cause coding errors by coding officers at the hospital.
RANCANGAN USER INTERFACE FORMULIR LAPORAN OPERASI DI RUMAH SAKIT UMUM DAERAH KABUPATEN KEDIRI (RSKK) Deni Luvi Jayanto; Zidan Jihad Muhammad; Roma Firmansyah
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.43

Abstract

Operational form reports which were recorded manually, of course, the results were less effective in terms of saving time and costs. The used of electronic operating reports provides convenience in terms of operation. Digital archiving to a computer makes it easier in terms of data management and distribution. The purpose of this study was to recommend for the Kediri District General Hospital (RSKK) by designing an electronic operation report design by strengthening the interface design, color and input. This study used observation and interviews with two medical record officers. The results of this study were the use of the operating report form in RSKK the recording was still done manually. Then the researchers designed an interface design that was tailored to the wishes of the officers who emphasized the basic color of gray, a simple layout and easy input methods. It can be concluded that it has resulted in the design of an electronic operation report form design that was integrated in the operating report system. This study has suggested implementing the use of an electronic operating reporting system that makes it easier for officers to operate it in the RSKK environment.
ANALISIS KEBUTUHAN APLIKASI WMA (WORKLOAD MEASUREMENT ANALYSIS) BERBASIS ANDROID UNTUK PERHITUNGAN ANALISIS BEBAN KERJA DI RSI AMINAH BLITAR Shofa Athur Rosyida; Dea Allan Karunia Sakti; Rahmadyo Yudhi Prabowo
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.44

Abstract

Aminah Islamic Hospital in Blitar City has workload problems, including calculations that are still done manually, long workload calculation formulas that also make it difficult for officers to carry out monitoring, rarely do evaluations resulting in uneven workloads, and. In this 4.0 era, it is possible to have an information system to assist in the process of calculating workload analysis. In making an information system analysis is needed according to user needs. Needs analysis is useful for determining what information systems should be done in a problem solving. This is done to identify strengths, weaknesses, and opportunities for improvement. The purpose of this study was to analyze the needs of the Android-based WMA (Workload Measurement Analysis) application for calculating workload analysis at RSI Aminah Blitar. This research method uses descriptive research with a qualitative approach. This study resulted in an analysis of the needs of the WMA application using an Android-based smartphone. The WMA application menu consists of a login display, data input, conclusion, and history so as to produce a WMA application that fits user needs to calculate workload requirements analysis at RSI Aminah Blitar.
ANALISIS KEBUTUHAN RAK PENYIMPANAN DOKUMEN REKAM MEDIS AKTIF DI PUSKESMAS KENDALKEREP MALANG Prima Soultoni Akbar; Tsalits Maulidah Hariez
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.45

Abstract

Medical record should be kept in store shelves that kept confidential, to avoid damage and officers in the medical record and return.So that this be effective and efficient store needs planning needs to be sufficient to keep within a certain period of time to the time will come and facilitate the back by officers.in storage of Puskesmas Kendalkerep record, not optimal because there are still kept are right on top in addition to store shelves triggered by the lack of store shelves so that it difficult to find the medical record can slow the documents and the medical record not yet destroyed had to be destroyed.Puskesmas kendalkerep also have not just calculate the store shelves. The research is descriptive qualitative research,  observing and analyzing the documents record store shelves puskesmas kendalkerep.The way the collection of data using observation and interview.The observation is made by means of observing, noted, and measuring the amount of patient visits, the thickness of the medical record, size store shelves and calculate the store shelves with watson and trend analysis method.The number of active medical record store shelves documents required to 5 years woultd go to 9 unit so it needs additional 4 shelf unit
HUBUNGAN KELENGKAPAN INFORMASI REKAM MEDIS DENGAN KEAKURATAN KODE DIAGNOSIS DI RUMAH SAKIT Andra Dwitama Hidayat; Krisnita Dwi Jayanti; Dianti Ias Oktaviasari; Intan Ayudya Novitasari
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.46

Abstract

Accuracy in determining the diagnosis code was something that must be considered, an accurate code was obtained with information that was able to support the coder in determining the diagnosis code. The accuracy of diagnosis codes was very important in the fields of education, research, national health statistics, quality of hospital services, and the basis for decision-making. This study aims to analyze the relationship between completeness of medical record information and accuracy of the diagnosis code in the hospital. The method used  descriptive analytic with a retrospective approach. The study population consisted of 6,069 inpatient medical record documents with a sample of 375 documents taken using simple random sampling technique. Based on the results of statistical tests using Chi-square, a p value of was obtained that there was a relationship between the completeness of medical record information and the accuracy of the diagnosis code at the hospital. Evaluation of the completeness of each medical record documents for a certain period of time was highly recommended to improve the accuracy of the diagnosis code.
SISTEMATIS REVIEW TENTANG PENGOBATAN TELEMEDICINE : EFEKTIVITAS, EFISIENSI, DAN KEPUASAN PASIEN Anis Ansyori; Fita Rusdian Ikawati; Retno Dewi Prisusanti; Achmad Jaelani Rusdi; Lilik Afifah; Untung Slamet Suhariyono
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.47

Abstract

Telemedicine, the use of digital technology and communication for remote healthcare services, has seen rapid development and offers potential improvements in accessibility and efficiency in healthcare services. However, the adoption and implementation of telemedicine also face various challenges, including data privacy and security, technological infrastructure readiness, and legal and regulatory barriers. This study aims to evaluate the effectiveness, efficiency, and patient satisfaction in the use of telemedicine based on existing scientific evidence. This study employs a systematic review methodology of related telemedicine studies. The results of this review are summarized and form the basis for further discussion about the effectiveness of telemedicine, challenges in its implementation, and its implications for the healthcare sector and further research. Recommendations are provided based on the findings of this review for future research or practice focusing on enhancing the effectiveness, efficiency, and patient satisfaction in the use of telemedicine and overcoming challenges in its implementation.
KEAKURATAN KODE DIAGNOSIS FRAKTUR DAN EXTERNAL CAUSES DI RSUD MARDI WALUYO KOTA BLITAR Nurhadi Nurhadi; Krisnita Dwi Jayanti; Andra Dwitama Hidayat; Sevi Oktrianadewi; Eva Firdayanti Bisono; Endah Retnani Wismaningsih; Elok Rizma Hapsari; Wahyu Wijaya Widiyanto
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.48

Abstract

Diagnostic codification must fulfill 10 characteristics of quality data, namely one of which is accurate, namely the truth and validity of data values. External Causes are external causes of fracture cases which classify based on the place and activity of the incident. It is very important that external causes codes are documented in medical record files for financing analysis, health services and reporting. The purpose of this study was to determine the accuracy of the fracture diagnosis code and external causes at Mardi Waluyo Hospital, Blitar City in 2021. The research method used a retrospective descriptive. The sampling technique is simple random sampling, with 52 samples. The implementation of coding at Mardi Waluyo Hospital, Blitar City, was carried out by coder officers and was in accordance with the policies and standard operating procedures at the hospital. The level of accuracy of the fracture diagnosis code with a percentage of 85% is included in the category that needs improvement and external causes with a percentage of 6% is included in the unsatisfactory category. The inaccuracy of the external causes code is caused by the use of the 5th character or the activity code that has not yet been coded. The inaccuracy of the officers in coding caused the resulting code to be inaccurate, so it was suggested that filling out medical record documents must be filled in completely and clearly to support proper and accurate coding of fractures and external causes so as to produce a better percentage of accuracy.
GAMBARAN KELENGKAPAN PENGISIAN FORMULIR RAWAT JALAN DITINJAU DARI ASPEK HUKUM KESEHATAN DI PUSKESMAS SEMEN KABUPATEN KEDIRI  TAHUN 2020 AG Nugroho Pudji Lestarjo; Indah Susilowati; Krisnita Dwi Jayanti; Sabila Ainaya Nazilla
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.49

Abstract

  Puskesmas is health service facilities that are implementing publih health efforts and individual health effort which is also obliged to carry out a medical record. The purpose of this study was to determine the completeness of filling out outpatient forms in terms of health legal aspects at the Semen Health Center, Kediri Regency in 2020. This type of research was descriptive with a retrospective approach. Collecting data by observation and interviews. Sampling used simple random sampling, namely 10 outpatient medical record documents in 2020. The results obtained were from 10 incomplete samples (6%) which were filled in completely (4%) item incompleteness contained in the writing of the icd10 code and the signature of the officer. This is not in accordance with Permenkes number 269 year medical record and Permeneks Number 46 Year 2015 abaout Accreditation of Puskesmas Which requires that in every medical record should be named and signatures a doctor or other health workers directly providing health services. In addition fill forms a medical record complete must be filled because it will become the foundation in giving the diagnosis next and knows the way a patient. Should be done socialization fill forms outpatient done by the head of this, to avoid incompleteness fill forms outpatient.
TINJAUAN LITERATUR ANALISIS YURIDIS MANAJEMEN KERAHASIAAN REKAM MEDIS ELEKTRONIK Achmad Jaelani Rusdi; R. A. Rengganis Ularan
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.50

Abstract

This study focuses on the importance of managing the confidentiality of electronic medical records (EMR) in the digital era as part of patients' privacy rights and the responsibilities of healthcare facilities. In Indonesia, several regulations have been established to protect patient data, such as Law No. 29 of 2004 on Medical Practice, Law No. 44 of 2009 on Hospitals, and the Information and Electronic Transactions Law (ITE) No. 19 of 2016, yet implementation continues to face significant challenges. This study uses secondary data from regulations and related literature to identify obstacles and the effectiveness of EMR data protection. The findings indicate that limited technology, insufficient understanding among healthcare personnel, and low patient awareness of their data protection rights hinder optimal confidentiality safeguards. Additionally, oversight of data access within hospitals is deemed inadequate. Increased education for healthcare workers, heightened patient awareness, and strengthened security infrastructure in healthcare facilities are essential to achieving improved patient data protection.

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